NCLEX/CGFNS Review Notes in Psychiatric Nursing by Lyle, RN

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** Some notes borrowed from a compilation called MIKE’s NOTES

Types of Coping Mechanisms

1. Compensation - extra effort in one area to offset real or imagined lack in another area
o Example: Short man becomes assertively verbal and excels in business.
2. Conversion - A mental conflict is expressed through physical symptoms
o Example: Woman becomes blind after seeing her husband with another woman.
3. Denial - treating obvious reality factors as though they do not exist because they are consciously intolerable
o Example: Mother refuses to believe her child has been diagnosed with leukemia. "She just has the flu."
4. Displacement - transferring unacceptable feelings aroused by one object to another, more acceptable substitute
o Example: Adolescent lashes out at parents after not being invited to party.
5. Dissociation - walling off specific areas of the personality from consciousness
o Example: Adolescent talks about failing grades as if they belong to someone else; jokes about them.
6. Fantasy - a conscious distortion of unconscious wishes and need to obtain satisfaction
o Example: A student nurse fails the critical care exam and daydreams about her heroic role in a cardiac arrest.
7. Fixation - becoming stagnated in a level of emotional development in which one is comfortable
o Example: A sixty year old man who dresses and acts as if he were still in the 1960's.
8. Identification - subconsciously attributing to oneself qualities of others
o Example: Elvis impersonators.
9. Intellectualization - use of thinking, ideas, or intellect to avoid emotions
o Example: Parent becomes extremely knowledgeable about child's diabetes.
10. Introjection - incorporating the traits of others
o Example: Husband's symptoms mimic wife's before she died.
11. Projection - unconsciously projecting one's own unacceptable qualities or feelings onto others
o Example: Woman who is jealous of another woman's wealth accuses her of being a gold-digger.
12. Rationalization - justifying behaviors, emotions, motives, considered intolerable through acceptable excuses
o Example: "I didn't get chosen for the team because the coach plays favorites."
13. Reaction Formation - expressing unacceptable wishes or behavior by opposite overt behavior
o Example: Recovered smoker preaches about the dangers of second hand smoke.
14. Regression - retreating to an earlier and more comfortable emotional level of development
o Example: Four year old insists on climbing into crib with younger sibling.
15. Repression - unconscious, deliberate forgetting of unacceptable or painful thoughts, impulses, feelings or acts
o Example: Adolescent "forgets" appointment with counselor to discuss final grades.
16. Sublimation - diversion of unacceptable instinctual drives into personally and socially acceptable areas.
o Example: Young woman who hated school becomes a teacher.

Elizabeth Kubler-Ross: Five Stages of Grief

1. Denial
a. Unconscious avoidance which varies from a brief period to the remainder of life
b. Allows one to mobilize defenses to cope
c. Positive adaptive responses - verbal denial; crying
d. Maladaptive responses - no crying, no acknowledgement of loss
2. Anger
a. Expresses the realization of loss
b. May be overt or covert
c. Positive adaptive responses - verbal expressions of anger
d. Maladaptive responses - persistent guilt or low self esteem, aggression, self destructive ideation or behavior
3. Bargaining
a. An attempt to change reality of loss; person bargains for treatment control, expresses wish to be alive for specific events in
near future
b. Maladaptive responses - bargains for unrealistic activities or events in distant future
4. Depression and Withdrawal
a. Sadness resulting from actual and/or anticipated loss
b. Positive adaptive response - crying, social withdrawal
c. Maladaptive responses - self-destructive actions, despair
5. Acceptance
a. Resolution of feelings about death or other loss, resulting in peaceful feelings
b. Positive adaptive behaviors - may wish to be alone, limit social contacts, complete personal business
Ego Defense Mechanisms

Denial—failure to acknowledge thought

Displacement—redirect feelings to more acceptable subject

Projection—attributing your feelings to someone else

Undoing—attempt to erase an act, thought or feeling

Compensation—attempt to overcome shortcoming

Symbolization—less threatening object used to represent another

Substitution—replacing unacceptable or unobtainable object to one that is acceptable or attainable

Introjection—symbolic taking into oneself the characteristics of another

Repression—unacceptable thoughts kept from awareness

Reaction formation—expressing attitude opposite of unconscious wish or fear

Regression—returning to an earlier developmental phase

Dissociation—detachment of painful emotional conflicts from consciousness

Suppression—consciously putting thought out of awareness

Dying patient: Denial, Anger, Bargaining, Depression, Acceptance

Bipolar Disorder Assessments Bipolar Disorder Implementations

• Disoriented, flight of ideas • Meet physical needs first
• Lacks inhibitions, agitated • Simplify environment
• Easily stimulated by environment • Distract and redirect energy
• Sexually indiscreet • Provide external controls
• Affective disorder • Set limits: escalating hyperactivity
• Maintain contact with reality • Use consistent approach
• Elation is defense against underlying • Administer Lithium (help Manic Phase of Bipolar, keep
depression hydrated)
• Manipulative behavior results from poor • Increase awareness of feelings through reflection
self-esteem

Schizophrenia Assessments Schizophrenia Types Schizophrenia Implementations

• Withdrawal from relationships and world
• Inappropriate display of feelings
• Hypochondriasis
• Suspiciousness
• Inability to test reality, regression
• Hallucinations—false sensory
perceptions
• Delusions—persistent false beliefs;
grandeur (feel higher rank); persecutory
(beliefs to be a victim); ideas of
reference (see people talking think
talking about them)
• Loose associations
• Short attention span
• Inability to meet basic
needs: nutrition, hygiene
• Regression
• Disorganized—inappropriate
behavior, transient hallucinations
• Catatonic—sudden onset mutism,
stereotyped position, periods of
agitation
• Paranoid—late onset in life,
suspiciousness, ideas of
persecution and delusions
• Maintain safety—protect from erratic behavior
• With hallucination—do not argue, validate reality,
respond to feeling tone, never further discuss
voices (don’t ask to tell more about voices)
• With delusions—do not argue, point out feeling
tone, provide diversional activities
• Meet physical needs
• Establish therapeutic relationship
• Institute measures to promote trust
• Engage in individual, group, or family therapy
• Encourage client’s affect
• Accept nonverbal behavior
• Accept regression
• Provide simple activities or tasks

Paranoid Assessments Paranoid Implementations

 Suspiciousness  Establish trust
 Cold, blunted affect  Low doses phenothiazines for anxiety
 Quick response with anger or rage  Structured social situations

Schizoid Assessments Schizoid Implementations

 Shy and introverted  Establish trust
 Little verbal interaction  Low doses phenothiazines for anxiety
 Few friends  Structured social situations
 Uses intellectualization

Schizotypal Assessments Schizotypal Interventions

 Eccentric  Establish trust
 Suspicious of others  Low doses neuroleptics to decrease psychotic symptoms
 Blunted affect  Structured social situations
 Problems with perceiving, communicating
Antisocial Assessments Antisocial Implementations
 Disregards rights of others  Firm limit-setting
 Lying, cheating, stealing, promiscuous  Confront behaviors consistently
 Lack of guilt  Enforce consequences
 Immature  Group therapy
 Irresponsible 
 Associated with substance abuse

Borderline Assessments Borderline implementations

 Brief and intense relationships  Identify and verbalize feelings
 Blames others for own problems  Use empathy
 Impulsive, manipulative  Behavioral contract
 Self-mutilation  Journaling
 Women who have been sexually abused  Consistent limit-setting
 Suicidal when frustrated, stressed  Group therapy

Narcissistic Assessments Narcissistic Implementations

 Arrogant lack of feelings and empathy for others  Mirror what client sounds like
 Sense of entitlement  Limit-setting
 Uses others to meet own needs  Consistency
 Shallow relationships  Teach that mistakes are acceptable
 Views self as superior to others

Histrionic Assessments Histrionic Implementations

 Draws attention to self  Positive reinforcement for other centered behaviors
 Somatic complaints  Clarify feelings
 Temper tantrums, outbursts  Facilitate expression of feelings
 Shallow, shifting emotions
 Cannot deal with feelings
 Easily influenced by others

Dependent Assessments Dependent Implementations

 Passive  Emphasize decision-making
 Problem working independently  Teach assertiveness
 Helpless when alone  Assist to clarify feelings and needs
 Dependent on others for decisions
 Fears loss of support and approval

Avoidant Assessments Avoidant Implementations

 Socially uncomfortable  Gradually confront fears
 Hypersensitive to criticism, Lacks self-confidence  Discuss feelings
 Fears intimate relationships  Teach assertiveness
 Increase exposure to small groups

Obssessive-compulsive Assessments Obssessive-compulsive Implementations

 High personal standards for self and others  Explore feelings
 Preoccupied with rules, lists, organized  Help with decision-making
 Perfectionists  Confront procrastination
 Intellectualize  Teach that mistakes are acceptable

Manipulative behavior Assessments Manipulative Behavior Implementations

 Unreasonable requests for time, attention, favors
 Divides staff against each other
 Intimidates others
 Use seductive or disingenuous approach
 Use consistent undivided staff approach
 Set limits
 Be alert for manipulation
 Check for destructive behavior
 Help client to see consequences of behavior

Acute Alcohol Intoxication Acute Alcohol Implementations

 Drowsiness  Protect airway
 Slurred speech  Assess for injuries
 Tremors  Withdrawal assess
 Impaired thinking  IV glucose
 Belligerence  Counsel about alcohol use
 Loss of inhibitions
Alcohol Withdrawal Assessments
 Tremors
 insomnia
 anxiety
 hallucinations
Chronic Alcohol Dependence Assessments
• Persistent incapacitation
• Cyclic drinking or “binges”
• Others in family take over client’s role
• Family violence
Wernicke’s Syndrome Assessments
• Confusion
• Diplopia, nystagmus
• Ataxia
• Apathy
Korsakoff’s Psychosis Assessments
• Memory disturbances with confabulation
• Learning problems
• Altered taste and smell
• Loss of reality testing
After WithdrawalDelirium Tremens Alcohol Withdrawal Implementations
Assessments  Monitor vital signs, especially pulse
 Disorientation  Administer sedation, anticonvulsants,
 Paranoia thiamine (IM or IV), glucose (IV)
 Ideas of reference  Seizure precautions
 Suicide attempts  Quiet, well-lighted environment
 Grand mal convulsions  Stay with patient
Chronic Alcohol Dependence Implementations
• Identify problems related to drinking
• Help client see problem
• Establish control of problem
• Alcoholics anonymous
• Antabuse
• Counsel spouse and children
Wernicke’s Syndrome Implementations
• Thiamine (IM or IV)
• Abstinence from alcohol
Korsakoff’s Psychosis Implementations
• Balanced diet
• Thiamine
• Abstinence from alcohol